Provider Demographics
NPI:1295792059
Name:WIEDER, FREDDA EDMEE (PHD)
Entity type:Individual
Prefix:DR
First Name:FREDDA
Middle Name:EDMEE
Last Name:WIEDER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 WESTMINSTER RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-2401
Mailing Address - Country:US
Mailing Address - Phone:718-859-1162
Mailing Address - Fax:
Practice Address - Street 1:164 ARGYLE RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3402
Practice Address - Country:US
Practice Address - Phone:718-859-1162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV00221Medicare ID - Type Unspecified